Lawmakers Scrutinize PBM Role in Oral Chemotherapy Cost Barriers

Prior authorization, fail-first step therapy, and market consolidation among pharmacy benefit managers (PBMs) are driving up out-of-pocket costs for oral chemotherapy, according to testimony before the House Oversight Committee's Subcommittee on Health Care and Financial Services.¹

The hearing, "Unequal Treatment: Addressing the Drivers of Unaffordability for Oral Chemotherapy," held September 15, 2026, examined why cost-sharing for oral cancer drugs so often exceeds that of intravenous (IV) chemotherapy and how PBMs have shaped those disparities. Witnesses included Ted Okon, MBA, executive director of Community Oncology Alliance (COA), and Sheetal M. Kircher, MD, clinical practice director and medical director of the Cancer Survivorship Institute at Northwestern University.

Coverage Splits Along How a Drug Is Delivered

Kircher testified that IV chemotherapy is covered under a patient's medical benefit while oral chemotherapy falls under the pharmacy benefit, a distinction she said has real consequences for whether patients receive care at all. She described patients receiving a call informing them that their cost-sharing responsibility for a cancer medication is $1000 before the drug can be shipped; if a patient cannot pay, the prescription goes undispensed. In a study of more than 10,000 patients prescribed oral cancer drugs, those facing out-of-pocket costs above $500 were 4 times more likely to abandon treatment than patients whose costs were $100 or less, she testified.

“I think in cancer specifically, the drugs have changed so much over the last 20, 30 years,” said Kircher. “Where we did used to only have IV chemotherapy, and even in the 15 years that I’ve been practicing, the science has evolved into a space where not only orals… Now we’re going to have a lot more immunotherapy, CAR-T therapy, different types of infusions that will need to keep up with this antiquated way that we really finance the chemotherapy, locking us in to a bucket that really doesn’t make sense for oncology anymore.”

PBM Market Control Draws Scrutiny

Okon testified that 3 PBMs control roughly 80% of the prescription drug market and that each is owned by an insurance company, in some cases one that also owns the physician practices filling the prescriptions, citing UnitedHealthcare as an example. He said this consolidation gives PBMs leverage to extract rebates and steer prescribing toward the highest-priced drugs.

A 2026 COA survey found more than 96% of community oncology practices had observed patients struggling because of insurer-imposed step therapy, and the same share reported that insurance policies interfere with physician-recommended treatment.

Parity Bill Would Close a Gap for Self-Funded Plans

Subcommittee Chairman Glenn Grothman (R, Wisconsin) noted that 43 states and the District of Columbia have passed oral chemotherapy parity laws capping cost-sharing for oral cancer drugs at IV-equivalent levels, but that those laws do not reach self-funded employer plans, which cover roughly 2 of every 3 Americans, and instead fall under the federal Employee Retirement Income Security Act (ERISA). Grothman has reintroduced the Cancer Drug Parity Act, H.R. 4101, to amend ERISA so self-funded plans covering IV anticancer drugs must offer no-less-favorable cost-sharing for medically necessary oral anticancer drugs.

The bipartisan bill has 10 cosponsors and remains in the early stages of the legislative process after being referred to the House Committee on Education and Workforce.²

“I think what we need to build on it, as I said, Dr. Kircher said as well too, is we need to build on it in terms of having no prior authorization and no fail-first-step therapy as well too,” said Okon.¹ “But everything we do, we have to understand everything that Congress does here is a step in the right direction in terms of PBMs and insurers and certainly oral cancer parity.”

References

1. Hearing wrap up: making lifesaving care more affordable for Americans. House Committee on Oversight and Government Reform. September 15, 2026. Accessed September 16, 2026. https://oversight.house.gov/release/hearing-wrap-up-making-lifesaving-care-more-affordable-for-americans/
2. H.R. 4101 (IH) — Cancer Drug Parity Act of 2025. GovInfo, US. Government Publishing Office. June 24, 2025. Accessed September 16, 2026. https://www.govinfo.gov/app/details/BILLS-119hr4101ih